ANTI CRAVING MEDICATIONS. Marla D. Kushner, DO, FACOFP, FASAMd, FSAHM

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1 ANTI CRAVING MEDICATIONS Marla D. Kushner, DO, FACOFP, FASAMd, FSAHM 1

2 VIVITROL NALTREXONE FOR EXTENDED RELEASE INJECTABLE SUSPENSION (LONG ACTING SHOT) 2

3 Relevant drugs: Opiates, heroin, alcohol How it works: Vivitrol is a competitive opioid antagonist. This means that it occupies the sites in the brain that opioids and alcohol normally bind to. With Vivitrol, there are no more available spaces for additional opiates or alcohol to bind to. This results in the other drugs inability to produce their effects, including euphoria. Even though Vivitrol may block the intense high from opioids, it does not prevent good feelings that come from other naturally pleasurable activities, i.e. only subsets of opiate receptors are blocked, thus allowing natural opiate receptors to bind, for example, endorphins from exercise. 3

4 Vivitrol: Who can take it? They must meet the following Criteria: -Have not taken any opiates/heroin for at least 7-10 days -Are not actively drinking at time of initiation -Are able to not drink alcohol in an out-patient setting (not under continuous supervision) -Are able to follow-up each month before medication effects expire.

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6 Benefits of Vivitrol: Patients will not get high or drunk even if they use and drink. This decreases the temptation of relapse. There is no need to remember to take a medication daily. There is no need to keep medication in the house. This means it will not be lost or stolen. Dosing is standardized 380 mg each month. The medical professional administering the shot witnesses the dosing. Vivitrol is an injection that slowly releases over one month. Thus you do not have to remember to take a pill, or worry about how your body metabolizes the medication (i.e. in cases of liver damage).

7 Drawbacks of Vivitrol: It is expensive. Insurance can help ($1, manufacturer s price). It is essential to receive each shot within 1 month or a few days less than 1 month of the previous shot. Side effects are uncommon but possible: liver damage, depression, suicidality, nausea/vomiting/ diarrhea, allergic reaction, muscle soreness at site of injection. Vivitrol treats the physical dependence on opioids and alcohol, but further psychosocial interventions (such as counseling and group therapy) are often required to enable people to maintain abstinence.

8 DANGER: While on Revia or Vivitrol, patients become opiate naïve. This means that their bodies can no longer handle the amount of opiates that they may have been used to before. Therefore, if a patient who has been taking ReVia or Vivitrol relapses, it is easy to overwhelm the body s ability to handle the opiates and overdose and death are more likely.

9 REVIA Generic: naltrexone hydrochloride (pill)

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11 Relevant drugs: Opiates, heroin, alcohol

12 How it works: ReVia and Vivitrol are different forms of naltrexone but, whereas Vivitrol is the longacting shot form, ReVia is the short-acting pill form. Like Vivitrol, it occupies the sites in the brain that opiates, heroin, and alcohol act on. This prevents these drugs from producing a high, buzz, or euphoria.

13 Who can take it? Patients seeking medical assistance during recovery of addiction may take ReVia if they meet the following criteria: -Have not taken any opiates/heroin for at least 7-10 days -Are not actively drinking at time of initiation -Are able to not drink alcohol in an out-patient setting (not under continuous supervision) -Are reliable to commit to taking the pill every day and will not skip doses either intentionally or unintentionally

14 Benefits of ReVia: Patients will not get high or drunk even if they use and drink. This decreases the temptation of relapse. The medication s potency is consistent over the course of a month, as opposed to Vivitrol. No shot is required so side effects like muscle soreness and a lump at the site of injection are not an issue. It is relatively inexpensive ($ manufacturer s price for 30 pills).

15 Drawbacks of ReVia: The patient must be willing and able to take the pill every day. There is a possibility of the pills getting lost or stolen. Side effects are possible. Nausea is the most common one and can be decreased by taking the pill with food. Other side effects: liver damage, diarrhea, depression/suicidality, allergic reaction

16 Other facts about Revia: It will NOT make you high or give you a sense of euphoria. It will NOT make you sick if you use/drink while on it. It is NOT addictive.

17 *As with all anti-craving medications, ReVia is meant to be used alongside psychological and social recovery measures. It is not meant to be used alone for recovery.

18 CAMPRAL Generic: acamprosate (pill)

19 Relevant drug: Alcohol

20 How it works: The way that Campral works is not completely understood. It is a GABA agonist and a glutamate antagonist which means that it effects chemicals in the brain related to alcohol use. By interfering with glutamate s ability to bind in the brain and enhancing GABA activity in the brain, Campral is somehow able to bring a chemical balance to the brain which decreases alcohol cravings.

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22 Who can take it? Patients seeking medical assistance during recovery from alcohol may be candidates for Campral if s/he has stopped drinking alcohol and is finished with withdrawal. It is recommended to start Campral as soon as a patient is finished with withdrawal. If a patient relapses, it is recommended to continue the medication.

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24 Benefits of Campral: It has been shown to decrease cravings for alcohol in people recovering from alcohol abuse. It will NOT make a patient sick if s/he drinks while taking the medication. This makes some patients more likely to take the medication everyday. It is considered safe and will not endanger the patient s life if a relapse occurs while on medication.

25 Drawbacks of Campral: A patient must have already gone through withdrawal before s/he can begin taking Campral. It becomes less and less effective if a patient continues to drink while taking the medication. Standard dosing is 2 pills taken 3 times each day for a total of 6 pills daily. It can be difficult to remember to take the medication on schedule. Can be expensive ($500 - $550 manufacturer s price for standard 1-month supply). Insurance can help. Side effects are possible. Diarrhea is the most common one.

26 Buprenorphine and naloxone (film or tablet)

27 Relevant drugs: Heroin, opiates

28 How it works: Buprenorphine is available as a pill and as a film that dissolves under the tongue. It is a combination of 2 different medicines buprenorphine and naloxone. Buprenorphine is a partial opioid agonist. This means that it acts in the same sites of the brain as opiates but does not have the full effects that opiates do. This minimizes withdrawal symptoms and cravings. Naloxone is a strong opioid antagonist. This means that it occupies the same sites in the brain that opiates do, leaving no open spaces for them to bind to. In this way, buprenorphine allows some stimulation of the opiate areas of the brain but in a controlled, plateaued manner.

29 Beginning Buprenorphine Induction: Before a patient can begin Buprenorphine, they must have already begun withdrawal. They can then come to the office where they will receive a urine drug screen because if certain drugs, like benzodiazepines, are in the patient s system, a life-threatening drug interaction can occur. If it is confirmed that the patient is in withdrawal and the urine drug screen results are okay then the patient will be given a prescription for a mild dose of Buprenorphine.

30 In My Practice: The patient will get the prescription filled and immediately return to the office to take the first dose under physician supervision. Half an hour later, they can take the second dose under physician supervision. At that time, the physician will create a gradually increasing dosing plan for the patient to follow until a follow-up visit 2-3 days later. At the follow-up visit, a more consistent dose will be planned. Until the patient s ideal buprenorphine dose is discovered, frequent follow-up appointments and smaller prescription quantities are necessary.

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32 Benefits of Buprenorphine: It minimizes cravings and withdrawal symptoms in patients recovering from addiction. Patients who have been addicted to heroin and/or opiates in the past will NOT get high from Buprenorphine and will have difficulty getting high from heroin/opiates while on Buprenorphine. It can be taken orally and does not require going to a special clinic for each dose.

33 Drawbacks of Buprenorphine: Patients become physically and psychologically dependent on buprenorphine successfully stopping Buprenorphine usually requires the assistance of a professional facility/hospital. Buprenorphine is a long-term medication and patients should not start it planning to stop taking it any time soon. Dosing can be tricky. Patient s must follow-up often with a physician who is experienced with buprenorphine and patients should never change their dose without talking to their physician first.

34 Stigma lots of people do not understand Buprenorphine and have misinformed ideas about how the medication works. Can be expensive pricing varies depending on dosage and form. Insurance and coupons can help. Side effects are possible most common ones include headache, pain, and withdrawal symptoms. These can be minimized with physician-guided dosing adjustments.!

35 CHANTIX Generic: Varenicline

36 Relevant Drug: Cigarettes/Nicoti ne

37 How it Works: Chantix is a non-nicotine containing prescription medicine. It is a partial nicotine agonist, thus it works in two ways. It targets nicotine receptors in the brain, attaches to them, and blocks nicotine from reaching them. It is believed that Chantix also activates these receptors, causing a reduced release of dopamine compared to nicotine. Usually Chantix is used for 12 weeks and cravings and smoking cessation status is reassessed. An additional 12 weeks may be appropriate if patient is still smoking or having cravings for cigarettes.

38 Who can take it? Anyone over the age of 18 who is considering quitting smoking. Those currently in pharmacologically managed opiate addiction. Research suggests that simultaneously treating nicotine addiction improves outcomes of opiate addiction. Smoking prevalence rates of 80% 95% among opiate addiction

39 Benefits of Chantix In one study quit rates were 56.4% compared to 11.6% in a placebo group Decreases physical cravings for nicotine Failure to address tobacco use may negatively affect pharmacologically managed opioid discontinuation (ie Naltrexone and Suboxone therapy). Opioid detoxification may offer a window of opportunity to expand smoking cessation treatment, hence improving opiate addiction outcomes. Cost effective, and significantly cheaper than smoking in the long term. Behavioral counseling and pharmacotherapy show to be the most successful steps to quit smoking.

40 Disadvantages of Chantix Abnormal dreams and nightmares, tiredness or insomnia and headaches GI side effects (nausea, vomiting, constipation, gas) Rash, shortness of breath of dry mouth Pregnancy category C (may be harmful to fetus but benefits may outweigh the risks)

41 Special tips for Chantix Set a Quit date and begin Chantix one week before quitting Take with full glass of water Do not deviate from dosage instructions as side effects may be more severe

42 Other Methods for assisting with smoking cessation Incorporating behavioral therapy and counseling Nicotine replacement such as patches, gum, lozenges Buproprion Clonidine

43 Thank You!